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      Women empowerment domains and unmet need for contraception among married and cohabiting fecund women in Sub-Saharan Africa: A multilevel analysis based on gender role framework

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          Abstract

          Background

          Low women empowerment, is a known contributing factor to unmet needs for contraception by limiting access to health services through negative cultural beliefs and practices. However, little is known about the association between unmet needs and domains of women empowerment in Sub-Saharan African (SSA) countries. Hence, this study aimed at assessing the influence of women empowerment domains on the unmet need for contraception in the region using the most recent Demographic and Health Survey (DHS) data (2016–2021).

          Methods

          The data for the study was derived from the appended women’s (IR) file of eighteen SSA countries. A weighted sample of 128,939 married women was analyzed by STATA version 16. The Harvard Institute’s Gender Roles Framework, which comprised of influencer, resource, and decision-making domains was employed to identify and categorize the covariates across three levels. The effects of each predictor on the unmet need for spacing and limiting were examined using a multivariable multilevel mixed-effect multinomial logistic regression analysis. Adjusted relative risk ratio (aRRR) with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

          Results

          The pooled prevalence of unmet needs for contraception was 26.36% (95% CI: 24.83–30.40) in the region, with unmet needs for spacing and limiting being 16.74% (95% CI: 16.55, 17.02) and 9.62% (95% CI: 9.45, 12.78), respectively. Among variables in the influencer domain, educational level, family size of more than five, parity, number of children, attitude towards wife beating, and media exposure were substantially linked with an unmet need for spacing and limiting. Being in the poorest wealth quintile and enrollment in health insurance schemes, on the other hand, were the two variables in the resource domain that had a significant influence on unmet needs. The overall decision-making capacity of women was found to be the sole significant predictor of unmet needs among the covariates in the decision-making domain.

          Conclusion

          Unmet needs for contraception in SSA countries were found to be high. Reproductive health program planners and contraceptive service providers should place due emphasis on women who lack formal education, are from low-income families, and have large family sizes. Governments should collaborate with insurance providers to increase health insurance coverage alongside incorporating family planning within the service package to minimize out-of-pocket costs. NGOs, government bodies, and program planners should collaborate across sectors to pool resources, advocate for policies, share best practices, and coordinate initiatives to maximize the capacity of women’s decision-making autonomy.

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          Most cited references84

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          A scoping review on determinants of unmet need for family planning among women of reproductive age in low and middle income countries

          Background Poor access and low contraceptive prevalence are common to many Low- and Middle-Income Countries (LMICs). Unmet need for family planning (FP), defined as the proportion of women wishing to limit or postpone child birth, but not using contraception, has been central to reproductive health efforts for decades and still remains relevant for most policy makers and FP programs in LMICs. There is still a lag in contraceptive uptake across regions resulting in high unmet need due to various socioeconomic and cultural factors. In this mixed method scoping review we analyzed quantitative, qualitative and mixed method studies to summarize those factors influencing unmet need among women in LMICs. Methods We conducted our scoping review by employing mixed method approach. We included studies applying quantitative and qualitative methods retrieved from online data bases (PubMed, JSTOR, and Google Scholar). We also reviewed the indexes of journals specific to the field of reproductive health by using a set of keywords related to unmet contraception need, and non-contraception use in LMICs. Results We retrieved 283 articles and retained 34 articles meeting our inclusion criteria. Of these, 26 were quantitative studies and 8 qualitative studies. We found unmet need for FP to range between 20 % and 58 % in most studies. Woman’s age was negatively associated with total unmet need for FP, meaning as women get older the unmet need for FP decreases. The number of children was found to be a positively associated determinant for a woman’s total unmet need. Also, woman’s level of education was negatively associated – as a woman’s education improves, her total unmet need decreases. Frequently reported reasons for non-contraception use were opposition from husband or husbands fear of infidelity, as well as woman’s fear of side effects or other health concerns related to contraceptive methods. Conclusion Factors associated with unmet need for FP and non-contraception use were common across different LMIC settings. This suggests that women in LMICs face similar barriers to FP and that it is still necessary for reproductive health programs to identify FP interventions that more specifically tackle unmet need. Electronic supplementary material The online version of this article (doi:10.1186/s12905-015-0281-3) contains supplementary material, which is available to authorized users.
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            Women's empowerment and fertility: a review of the literature.

            Women's empowerment has become a focal point for development efforts worldwide and there is a need for an updated, critical assessment of the existing evidence on women's empowerment and fertility. We conducted a literature review on studies examining the relationships between women's empowerment and several fertility-related topics. Among the 60 studies identified for this review, the majority were conducted in South Asia (n = 35) and used household decision-making as a measure of empowerment (n = 37). Overall, the vast majority of studies found some positive associations between women's empowerment and lower fertility, longer birth intervals, and lower rates of unintended pregnancy, but there was some variation in results. In many studies, results differed based on the measure of empowerment used, sociopolitical or gender environment, or sub-population studied. This article is one of the first evaluations of the literature assessing the relationships between women's empowerment and fertility. We identify several key issues that merit further investigation. Copyright © 2014 Elsevier Ltd. All rights reserved.
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              Factors Influencing Contraceptive Use in Sub-Saharan Africa: A Systematic Review

              The purpose of this study was to systematically review the literature regarding factors influencing contraceptive use in sub-Saharan Africa between 2005 and 2015. A total of 58 studies from twelve Sub-Saharan African countries were reviewed. Keywords were grouped using the PEN-3 cultural model. Negative factors prohibiting or reducing contraceptive use were women's misconceptions of contraceptive side-effects, male partner disapproval, and social/cultural norms surrounding fertility. Positive factors included education, employment, and communication with male partner. Increasing modern contraceptive use in Sub-Saharan Africa is a multi-faceted problem that will require community and systems wide interventions that aim to counteract negative perceptions and misinformation.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLOS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                8 September 2023
                2023
                : 18
                : 9
                : e0291110
                Affiliations
                [1 ] School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
                [2 ] Department of Public Health, College of Medicine and Health Sciences, Mizan Tepi University, Mizan, Ethiopia
                Obafemi Awolowo University, NIGERIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0002-5719-4294
                Article
                PONE-D-23-12294
                10.1371/journal.pone.0291110
                10491392
                37683011
                13b88e30-3f95-4e38-95bd-7453a86bcfa1
                © 2023 Habte et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 April 2023
                : 23 August 2023
                Page count
                Figures: 2, Tables: 10, Pages: 26
                Funding
                The author(s) received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Contraception
                Female Contraception
                Biology and Life Sciences
                Neuroscience
                Cognitive Science
                Cognitive Psychology
                Decision Making
                Biology and Life Sciences
                Psychology
                Cognitive Psychology
                Decision Making
                Social Sciences
                Psychology
                Cognitive Psychology
                Decision Making
                Biology and Life Sciences
                Neuroscience
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                Cognition
                Decision Making
                Social Sciences
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                Health Economics
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                Medicine and Health Sciences
                Health Care
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                Health Care
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                Medicine and Health Sciences
                Health Care
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Public and Occupational Health
                Socioeconomic Aspects of Health
                People and Places
                Population Groupings
                Age Groups
                Children
                People and Places
                Population Groupings
                Families
                Children
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Contraception
                Research and Analysis Methods
                Mathematical and Statistical Techniques
                Statistical Methods
                Regression Analysis
                Physical Sciences
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                Custom metadata
                The data supporting the findings of this study can be obtained in anonymized form from the Demographic and Health Survey website at https://www.dhsprogram.com upon reasonable request in the same manner as the authors. The authors did not have any special access privileges that others would not have.

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